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ANNEX H - Barangay Protection Order Application Form

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59 views

ANNEX H - Barangay Protection Order Application Form

Uploaded by

isiaahkhisses
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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ANNEX H

Republic of the Philippines


Province of _________________
City/Municipality _____________
Barangay __________________

BARANGAY PROTECTION ORDER (BPO) APPLICATION FORM

1. IF APPLICATION IS MADE BY AN APPLICANT OTHER THAN THE VICTIM

NAME OF APPLICANT:_________________________ DATE OF BIRTH:_________________


ADDRESS: __________________________________ CONTACT NO.:__________________
RELATIONSHIP TO VICTIM(S):__________________ OCCUPATION: __________________

2. IF APPLICATION IS MADE BY THE VICTIM-SURVIVOR

NAME OF VICTIM(S):_________________________ DATE OF BIRTH:_________________


ADDRESS: _________________________________ CONTACT NO.:__________________
OCCUPATION/SOURCE OF INCOME:_________________________________________________
CIVIL STATUS: ___ Single ___ Married ___ Widow ___ Separated ___ Legally Separated

3. NAMES OF CHILDREN DATE OF BIRTH SEX


__________________________________________ _______________ _________
__________________________________________ _______________ _________

OTHER CHILDREN UNDER THE VICTIM’S CARE DATE OF BIRTH SEX


____________________________________ _______________ _________
____________________________________ _______________ _________

4. NAME OF RESPONDENT:___________________ DATE OF BIRTH:________________


ADDRESS:__________________________________ CONTACT NO.:__________________
SEX:_______________ OCCUPATION/SOURCE OF INCOME:__________________________
CIVIL STATUS: ___ Single ___ Married ___ Widow ___ Separated ___ Legally Separated

5. RELATIONSHIP OF VICTIM TO RESPONDENT


__ Wife __ Former Wife __ Live-In Partner __ Dating Relationship __ Sexual Relationship

6. ACTS COMPLAINED OF: ____ Threats ____ Physical Injuries


DESCRIPTION:
_________________________________________________________________________________________
_________________________________________________________________________________________

7. DATE(S) OF COMMISSION: ______________


8. PLACE(S) OF COMMISSION:_______________________________________________________
9. IF APPLICANT IS NOT THE VICTIM, STATE THE CIRCUMSTANCES OF CONSENT:
_________________________________________________________________________________________
___________________________________________________________________________

APPLICANT/VICTIM:__________________________________ DATE:___________________
Signature over Printed Name

VERIFICATION OF THE PUNONG BARANGAY

I certify the victim and/or applicant for BPO who personally appeared before me is a bonafide
resident of this barangay and is the same person who supplied all the information and attest to
the correctness of said information.

_________________________
Punong Barangay

_________________________
Date Issued

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